Dry socket Oral Medicine Seminar

Faculty of Dentistry
20231

Performance : Deena Housheya & Soleen Abu-Taleb Supervisor : Dr. Ahmad Jarrar
 Objectives
• Introduction . • Signs and symptoms.
• Definition . • Normal socket vs dry
• Etiology . socket.
• Risk factors. • How to diagnose &
• Epidemiology. deal with it.
• References.
• Prevention.
 Introduction
• Many patients have more preoperative concerns about the sequelae
of surgery—such as pain, swelling, and complications—than about
the procedure itself especially if they have confidence in the surgeon.

• The surgeon can do many things to prevent the common

complications after surgery.

• This seminar will discuss briefly one of the important sequelae that
occur after extraction and how to treat it.
 Definition
• Dry socket is the unscientific term of “Alveolar Osteitis” .
• It isn’t infection, but inflammation of the bone marrow.

• It is also known as:

Painful socket
Localized osteomyelitis
Necrotic socket alveolitis

• It’s a the most common and painful complication after exodontia.

 Definition
• It refers to a post-extraction
socket , focal osteomyelitis,
with a partially or completely lost
blood clot and some or all of the
bone within the socket or around
the occlusal perimeter of it is
exposed(but with no
suppuration) in the days after
the extraction.
 Alveolar osteitis
(dry socket) after
mandibular wisdom
tooth extraction.
 Etiology
.The cause of AO isn’t fully clear •

It appears to result from high •

levels of fibrinolytic activity in and
.around the socket

Fibrinolysis results in lysis of blood •

clot and subsequent exposure of
.bone

Breakdown of the clot results •

from plasminogen pathway
activation, but the trigger is
• The fibrinolyric activity may result from to subclinical infections ,
inflammation of the marrow space of the bone , or other factors.

• AO also may result because not having been covered by a layer of

vital, persistent, healing epithelium.

• The patient may not be able to prevent food particles or the

tongue from mechanically stimulating the exposed bone,
which is acutely painful to touch, resulting in frequent acute
pain.
Risk factors
 Risk factors
• Several other risk factors for developing AO have been investigated,
including:
• Tobacco use.
• Poor oral hygiene.
• Excessive rinsing.
• Traumatic extraction.
• Pre-existing pericoronitis.
• Limited blood supply.
• Excessive vasoconstrictor in LA.
• Difficulty of extraction.
These factors have support in multiple publications, but the
.role of most others has not been demonstrated
 Epidemi
ology
• Almost all dry sockets occur after
the removal of lower molars.

• The occurrence of a dry socket

after a routine tooth extraction is
rare (2% of extractions) , but it’s
frequent after the removal of
impacted mandibular 3rd molars
and other lower molars (20% of
extractions in some series).
 Prevention
• Prevention of dry socket syndrome requires:
Minimizing trauma and bacterial contamination by the surgeon in the area of
surgery .

Perform atraumatic surgery with clean incisions and soft tissue reflection.

After the surgical procedure, the wound should be irrigated thoroughly with
large quantities of saline delivered under pressure , as from a plastic syringe.

Small amounts of antibiotic placed in the socket alone or in a gelatin sponge

have been shown to decrease the incidence of dry socket in lower 3rd molars and
other lower molars sockets.
• Smoking cessation is something all patients should consider to deter
several complications, including AO.

• Females should also be aware that their risk can increase, especially if
they are taking oral contraceptives.

• Controlling factors such as these could reduce the incidence of AO.

• Detailed post-operative instructions are always recommended, but this

has been investigated, and there was no significant decrease in AO rate
even when given.
• The prophylactic measure with the most support is the use of
chlorhexidine.
 Chlorhexidine
mouthwash
post-extraction
reduces dry
socket 50%
Normal socket versus
Dry socket
 Normal healing vs Dry
socket
Dry socket Normal Healing
Post-op pain lessens over the first days but then gets
.worse Levels of post-op pain gradually improve each day.

The socket appears empty.(only some or none of the The socket appears relatively full with blood clot and
original blood clot is visible.) .developing tissues

.Regions of exposed bone are visible .No visible exposed bone tissue

.Bad breath , foul odor coming from the extraction site . No associated breath odor

.Bad taste coming from the extraction site .No associated taste
 History &
physical
examination
• Cardinal symptom :
radiating moderate to severe
pain ↗️ intensity after tooth
extraction 1-5 days
postoperative / unrelieved by
analgesic.
• Halitosis is commonly
reported.
physical • Extraoral unremarkable / stable vital
signs/no frank signs of infection(no
examina leukocytosis expected )/ Rarely
lymphadenopathy and low grade

tion fever.
 physical
examinatio
n
• Intraoral complete or
partial broken down
blood clot within socket /
exposed bone(typical
clinical presentation)/
Panorama could rule out
remaining tooth
fragments or bone
sequestra .
• All parts of a dry socket lesion, except the exposed bone, can be
gently touched with a periodontal probe or an irrigation needle tip
without causing acute pain.
 Treatment
• The ttt of AO is dictated by the single therapeutic goal of relieving the
pain during the healing period.

• Ttt doesn’t hasten healing, so if pt didn’t treated no sequela other

than pain will exist.
Treatment
• Ttt is straightforward.

• Step1: irrigation of
the socket gently
with sterile saline.
 Treatment
• The socket shouldn’t be curetted down to bare bone
because this increases the amount of exposed bone
and pain.

• Usually the blood clot in not entirely and the part

that is intact should be retained.
 Treatment
• Topical local anesthetic gels can relieve pain shortly after irrigation,
and long-acting local anesthetics can provide immediate symptom
relief.

• Local anesthetics can be supplemented with oral analgesics, primarily

non-steroidal anti-inflammatory drugs (NSAIDs).
 Treatment
• Step 2 : The socket is gently
suctioned of excess saline,
and a small strip of
iodoform gauze soaked in
or coated with the
medication is inserted into
the socket , with a small
tag of gauze left trailing out
of the wound.
 Treatment
• Some common options of medicated dressing are:

zinc oxide eugenol or other obtundent dressings that include

compounds with analgesic or antibacterial action.
 Treatment
• The medication contains the following principal ingredients:
• Eugenol :which obtunds the pain from the bone tissue.
• A topical anesthetic such as benzocaine .
• Carrying vehicle such as balsam of Peru.

• It can be made by the surgeon’s pharmacist or obtained as a

commercial preparation from a dental supply house.
 Treatment
• The patient usually experiences profound relief from pain within 5
minutes.
• The dressing is changed every other day for the next 3 to 5days ,
depending on the severity of pain.
• The socket gently irrigated with saline at each dressing change.
• Once the patient’s pain has decreased ,the dressing shouldn’t be
replaced because it acts as a foreign body and prolongs healing.
Let’s go to
Quiz
 References
• Christopher Rohe1; Mark Schlam(May/29/2023).Alveolar
Osteitis.viewed in Nov/10/2023.https://www.ncbi.nlm.nih.gov
/books/NBK582137/

• John Mamoun,(25/April/2018),Dry Socket Etiology,Diagnosis and Clinical

Treatment Techniques ,https://doi.org/10.5125/jkaoms.2018.44.2.52

• Lane Aliana,Madden Hannah,(August/30/2021),How to Treat a Dry Socket,

https://pin.it/1xs5ZlV

• Contemporary Oral and Maxillofacial surgery, 7th edition .

Thank you